The international PIACO study: pattern of surgical approaches for acute surgical pathologies in Spain versus UK. Was conservative treatment and open surgery during COVID-19 the way to go?

Hector Guadalajara , Marina Yiasemidou* , José Luis Muñoz de Nova, Peter Sedman, Saul Fernandez Gonzalez , Sushil Maslekar, María Recarte Rico, Richard Egan, Luz Divina Juez, Kallingal Riyad, Javier García Septiem, Sonia Lockwood, Pablo Galindo Jara, Andrea Giorga, Mariana García Virosta, Julian Hance, Eduardo Lobo Martínez, Elena Martín-Pérez, Annabel Howitt , David Jayne , Ian Chetter, Damian García-Olmo and PIACO Collaboration Group

During the first wave of the SARS-CoV-2 pandemic, drastic restructuring of surgical services was applied, as part of a larger scheme aiming to protect health systems from being overwhelmed during the pandemic 1,2 . As a result of reserving resources to cope with the expected influx of patients with COVID-19, elective activity was postponed and acute surgical cases were treated preferably in an ambulatory rather than an inpatient setting [3][4][5] . Data during the early days of the pandemic, reporting worryingly high morbidity and mortality rates after surgery, led to acute cases being treated conservatively; surgery was reserved for severe cases or when conservative strategies had failed 5 .
A multicentre, comparative, international study was conducted in 16 centres in Spain and four in the UK, aiming to assess the impact of the COVID-19 pandemic and associated public health measures, on presentation and management of acute surgical pathologies.
Adult patients (older than 18 years) with a diagnosis of acute appendicitis, acute cholecystitis, acute diverticulitis, or perianal abscess (acute surgical inflammatory processes; ASIPs) during the national lockdown in each country (Spain, 14 March 2020 to 2 May 2020; UK, 23 March 2020 to 11 May 2020) were included. Patients were excluded if an ASIP had been diagnosed within 30 days before admission or if the admission was due to a scheduled surgery for definitive treatment of the ASIP. Patients with the above diagnoses within the same time frame the year before (Spain, 14 March 2019 to 2 May 2019; UK, 23 March 2019 to 11 May 2019) were historical controls.
A correlation was demonstrated between the reduction in ASIP cases from 2019 to 2020 and the daily number of COVID-19 cases reported in Spain during the lockdown interval (R = 0.413, P = 0.030, R 2 = 0.171), whereas, such a correlation was not demonstrated in the UK (R = 0.010, P = 0.944, R 2 = 0.0001029; Fig. 1).
The independent predictors of non-surgical treatment of appendicitis and cholecystitis were presenting diagnosis in the UK (appendicitis OR 0.026, P < 0.001; cholecystitis, OR 0.148, P = 0.031), non-severe condition at diagnosis (appendicitis OR 11.433, P = 0.036; cholecystitis OR 7.944, P = 0.022) and a COVID-19-positive diagnosis (OR 0.142, P < 0.001). Predictors for open surgery were presenting in the UK (OR 0.152, P < 0.001) and COVID-19-positive status (OR 0.112, P = 0.002) (Supplementary material). There were no differences in mortality between the two years. Severity at diagnosis was the only independent predicting factor for major complications (OR 3.148, P = 0.003) (Supplementary material). Further information regarding patient and disease characteristics can be found in the Supplementary material. Subgroup analysis showed patients who tested positive in the UK were significantly older in age (53 versus 73 years, P = 0.002) and had significantly higher Charlson co-morbidity index (CCI) (1 versus 4, P < 0.001). No such differences were noticed in Spain (Supplementary material). Patients who tested positive for COVID-19 were more likely to have severe ASIPs at the time of diagnosis (71 versus 16, P = 0.002) (Supplementary material). Furthermore, they were less likely to be treated surgically (285 versus 19 patients, P = 0.002) and were more likely to have severe complications (33 versus 8 patients, P = 0.044) regardless of whether they were treated surgically or not.
This study demonstrates a shift towards conservative treatment and open surgery during the first wave of the COVID-19 pandemic. The single factor independently associated with severe complications (Clavien-Dindo classification) was